Documentation
Should you chart "Pt had a good day."? Why or why not?
No. That is subjective information. Documentation should include specific observations instead.
How do you correct a written documentation error?
Draw one line through it, write "error", initial/date, the document correctly.
Which artery is used when taking a manual BP?
Brachial artery
Normal adult respirations are between these numbers per what unit of measure?
12-20 breaths per minute
At what temperature is a pt considered to have a fever?
Above 100.4F
This federal law protects pt health information.
HIPPA
What is the primary purpose of documentation?
To provide a written record of pt care, interventions and responses.
Using a cuff that is too small can cause the BP reading to be ________?
Falsely High
Why should respirations be counted without the pt knowing?
They may change their breathing if they know they are being observed.
Your pt just received pain medication, what should be documented next?
The pt's response to the medication.
Whose charts may you legally review?
Only pts assigned to your care
The nurses documentation should include which step of ADPIE after interventions?
Evaluation
How long in minutes should a pt avoid eating, drinking or smoking before an oral temperature is taken?
10 minutes
Which blood pressure reading is heard first with a stethoscope, and which follows second?
Systolic followed by diastolic
Name three things that can cause an inaccurate pulse oximeter reading.
Nail polish, Motion, Artificial Nails, Hypothermia, Low BP
Name 3 events that require immediate documentation.
Vital Signs, Med Admin, Pain Assessment, Change in status, Admission/Transfer/Discharge, response to treatment
List 3 of the 5 characteristics of quality documentation.
Factual, Accurate, Current, Organized, Complete
How should the pt be positioned for the most accurate BP reading?
Feet flat on the floor, back supported, arm supported at the level of the heart.
Name four symptoms of hypoxia.
Restlessness, Headache, Confusion, Difficulty breathing, rapid HR (tachycardia), rapid breathing (tachypnea), anxiety
List three things that help obtain an accurate BP.
Correct cuff size, Arm level with heart, feet flat on the floor, back supported, bare arm
Name 3 things found in the health record besides nursing notes.
Demographics, Labs, Vitals, Provider notes, Informed Consent, Living Will, Care Plans
What are two ways to maintain pt confidentiality?
Log out of computers, never share passwords, only access assigned pt records, never print records for personal use
Your pt has the following Vitals: BP 86/52, Temp 103.8*F, HR 132, RR 30, SpO2 87%. Which are abnormal and which one requires the MOST immediate intervention?
All Vitals are abnormal. SpO2 of 87% is the highest priority because it indicates hypoxemia requiring immediate attention. The fever, tachycardia, tachypnea and hypotension also require prompt evaluation.
Name all 5 Vital Signs
Blood pressure, Temperature, Heart Rate/Pulse, Respiratory Rate, Oxygen Saturation
Which pt should the nurse see first?
A.Temp 101.2F, HR88
B. BP 122/76, Pain 9/10
C. RR 10, SpO2 82%
D. HR 102 after walking with PT
C. The low RR and critically low oxygen saturation make this the highest priority.